Mr. Michael Bergin Michael Bunyan

Mr. Michael Bergin Michael Bunyan

W20044656

Substance Misuse, Addictions and Nursing Interventions

“Alcohol is frequently associated with many aspects of Irish social and cultural life and its use has become deeply woven into our national identity. For many, alcohol is also seen as a gateway to illicit drug use, particularly for young people, while poly-drug use- which very often includes alcohol- is now the norm among illicit drug users” (National Drugs Strategy, Department of Community, Rural and Gaeltacht Affairs, 2009, p.14).

Date of Submission: 24th April 2013

Estimated word count: 2750

Contents

Introduction 3

Benzodiazepines 4

Facts and Figures 5

Theories of Addiction 6

Biological – Disease Model of Addiction 6

Psychological – The Gateway Theory 7

Sociological – Skog’s Choice Theory 8

Nursing Implication & Challenges 9

Conclusion 11

References 12

Introduction

The enjoyable and sometimes socially inclusive nature of substance misuse will always be a part of the human condition and evidence of this can be seen throughout the world’s history, misuse of substances may not lead to problems, however, for some it can have life-changing consequences (Maremmani 2008, Smith 2013). The issue of substance misuse has been identified as a major sociological issue in modern Ireland (Department of Justice, Equality and Law Reform 2005). According to Kelleher (2007) one in four people who attend Irish emergency departments have substance misuse related injury or illness and a further one in eight would fulfil the criteria for clinical intoxication. With the increasing trends of substance misuse it is widely accepted that this misuse is exacerbating problems at an individual, familial and societal level (Kelleher & Cotter 2008).

In this paper there will be a focus on the category of drugs classified as sedatives and tranquillisers. More specifically on the group of drugs called Benzodiazepines (BZDs). The rationale behind choosing BZDs is that after this author’s numerous clinical placements during the past three years in different mental health settings, the misuse and the dependence of BZDs is a common problem that spans those settings. In this paper there will be a description of BZDs which will include their indications, mode of action and the dangers associated with their use. Following this description there will be a section on statistics associated with BZDs, this section will present the prevalence of misuse both nationally and locally in a south-eastern context. There will also be figures presented from a European and global point of view. The subsequent section will discuss differing theories of addiction. The final section will discuss the impact for healthcare provision with specific reference to mental health nursing, this will include the potential and challenges that might be encountered by mental health professionals.

Benzodiazepines

Dr Leo Henryck Stermbach is the person who has been attributed with the discovery of BZDs in the early sixties, the discovery of the first benzodiazepine Librium has been accredited to him, and its improved counterpart diazepam. During the years 1969 and 1982, diazepam was the most widely used benzodiazepine in the United States with a total of 2.3 billion doses sold in 1978 (Dell’osso & Lader 2013). As reported by Baldwin et al (2011), the hypnotic and anxiolytic actions of BZDs meant that they became widely prescribed before the realisation that both tolerance and dependence could occur.

The indications for the use of BZDs are moderate to severe anxiety disorder, panic disorder, acute alcohol withdrawal, status epilepticus and peri-operative use (BNF 2011). The mode of action of benzodiazepines as published by Richards (2009) is that they act on the GABAa receptor and enhance the response to GABA by aiding in the opening of GABA activated chloride channels, this in turn supervises inhibitory neurotransmission in the brain which leads to the signs and symptoms of anxiety. Within the current evidence it is clear that there are inherent dangers associated with the use of BZDs. In their study Wu et al. (2011) concluded that use of BZDs is very prevalent in mental health settings and that 62.9% of users are considered long term users. This point is supported by Anwar (2008) who stated that there is a risk for misuse as a result of tolerance and dependence. She continues to state that 88% of all patients are being inappropriately prescribed BZDs for longer than four weeks. Another danger associated with the long term use of BZDs is that of withdrawal. Withdrawal symptoms can be as high as 75% in long term users and these symptoms can lead to issues around medication compliance, also issues in the users’ professional and social lives (Saxon et al. 2010).

Facts and Figures

According to International Narcotics Control Board - INCB (2012), European Monitoring Centre for Drugs and Drug Addiction – EMCDDA (2012), Drugscope United Kingdom (2012) and the joint report from the National Advisory Committee on Drugs - NACD & Public Health Information and Research Branch – PHIRB (2011);

·  Total global licit production of BZDs in 2011 was 180 tonnes

·  56 tonnes of this 180 tonnes was diazepam

·  The leading manufacturers of BZDs are Italy (40%), China (13%), United States (13%) and Germany (9%)

·  BZDs are the most commonly prescribed mood altering drugs globally

·  In the United Kingdom (UK) 1 in 7 people admitted using BZDs at some time in the year

·  In the UK 1 in 40 admitted using BZDs throughout the year

·  In random testing in the UK 1.4% of drivers tested positive for BZDs

·  In the UK in 1979 30 million prescriptions were issued for BZDs versus 15 million in 1999.

·  National figures in Ireland have showed an increase in BZDs from 4.7% to 6.5%

·  Figures for the south-eastern region in Ireland have showed a decrease in BZD use from 13.3% to 12.7% but are still significantly higher than the national figures

Theories of Addiction

In this section there will be a discussion on theories of addiction. As West and Hardy (2006) stated in their book, knowledge of addiction theory is essential if one is to understand addiction itself. The approach to this section will use the biopsychosocial model of care. The rationale for this model of care is that for mental health nurses it is imperative to adopt a holistic approach to care. The idea of the biopsychosocial approach was first theorised in Rochester, New York by a psychiatrist named George Engel in 1977. He believed that a new model of medicine was needed. Holism or a holistic view was identified in the Ottawa Charter for Health Promotion in 1986 as a key component of health care (Povlsen and Borup 2011.

For one to be able to understand the following theories on addiction one must first understand what addiction is. Addiction/dependence is defined by the World Health Organisation (WHO 2013) as a strong desire or compulsion to take a substance, difficulty in controlling its use, the presence of a physiological withdrawal state, tolerance of the use of the drug, neglect of alternative pleasures and interests and persistent use of the drug, despite harm to oneself or others. This supports the biopsychosocial model of care as it is clear from the definition that the WHO encompasses this same approach, and in its diagnostic criteria in the International Classification of Disease 10 (ICD10).

In keeping with the biopsychosocial approach this author will discuss a theory from a biological, psychological and sociological context.

Biological – Disease Model of Addiction

As reported by West and Hardy (2006) “the disease model of addiction states that addiction involves pathological changes in the brain that result in overpowering urges” (p.76). Littrell (2011) in her research paper stated that in the previous two decades neuroscience research has expanded rapidly in the examination of brain activities that can assist in the explanation of addiction. She follows on to conclude that findings suggest that addiction and drug seeking behaviour can be activated outside of insightful awareness. These findings are supported when one looks at the anatomy and neuronal circuits of the brain. One of the pathways in the brain has been labelled the reward pathway. This area is activated by food, water, sex, exercise and drugs. The areas of the brain that affect the reward pathway are the ventral tegmental area (VTA) which consists of neurotransmitter neurons, the nucleus accumbens (NA) which is a collection of neurons, the NA plays an important role in the addiction effect, and finally, the amygdala which is involved in signalling the pre-frontal cortex with significant stimuli like the ones related to reward (Waugh and Grant 2010). When a substance is introduced to the body there can be an imbalance of neurotransmission in the VTA, in turn the brain becomes sensitised to these substances effectively treating the substance’s presence as normal, in time the brain readjusts neurotransmission to adapt to the substance (Arkins 2013). When the substance is then discontinued there is a physiological response by the body that is classified as withdrawal, in BZD withdrawal this can be a potentially fatal syndrome (Nielson et al. 2012). One of the diagnostic criteria in ICD10 for withdrawal syndrome is cravings, with reference to the disease model of addiction this could be explained by the corticotrophin releasing factor (CRF) involvement. Wand (2008) reports that the CRF system arbitrates the organic symptoms of withdrawal, this leads to increased levels of stress, this stress can lead to high levels of relapse in recovering addicts. The fact that BZDs have been proven to be addictive within a short period of time, it could be concluded that the addiction is caused by the introduction of such substances to the reward pathway which in turn leads to pathology of the brain.

Psychological – The Gateway Theory

West and Hardy (2006) describe the gateway theory as “a user of one drug, usually a drug with less addictive qualities, causes and individual to be more susceptible to using another, stronger, and potentially more addictive or harmful drug” (p.64). This theory is very pertinent to the mental health services in Ireland as there are numerous clinical examples of a client escalating their substance misuse from less dangerous substances to more dangerous forms of misuse. There are a number of pathways that an addict can follow with reference to this theory. Firstly, the initial drug could just give a “taste” of the reward that could be gained from using a stronger drug. Secondly, the addict might find themselves in influencing social circles that could lead to the use of stronger substances. Finally, the addict develops tolerance to the original drug and needs to use a more potent substance to achieve the same reward, which in turn has more negative consequences associated with it. It could be argued that the gateway theory could span the biopsychosocial model, but what is important to note is that whichever of the above pathways an addict follows that the thought process in deciding which pathway has its basis in psychology (Karazsia et al. 2012). This theory could be linked to the disease model of addiction in the sense that if the reward pathway discussed earlier is not satisfied then the altered thought processes of an addict can lead to irrational decisions which can lead an addict to try higher potency drugs. Another factor that can influence the thought process could be that of the environment that the person is in and the peer group they are associated with. Peer pressure has been identified as an important factor to be considered in an addict’s decision making and thought processes, when combined with the gateway theory it can be seen how an addict could potentially move to higher potency drugs like BZDs that have a lot more serious implications than so called “softer” drugs (Saddichha et al. 2007, Van Hout 2010).

Sociological – Skog’s Choice Theory

West and Hardy (2006) define Skog’s choice theory as “a theory that states that addiction can be regarded as a manifestation of conflicted choices that change as a function of the addict’s current preferences” (p.52). What has to be done with reference to this theory is to examine the factors that influence an addict’s choice. The societal influences and the environment that an addict finds themselves in cannot be ignored. Hansen et al. (2008) in their qualitative study surmised that addiction has massive implications on the family and society as a whole. Another societal issue that can influence an addict in their behaviour is stigma and being part of a marginalised group. In their study of 2932 people diagnosed with AIDS Roux et al. (2011) found that a higher proportion of the people who had disclosed their diagnosis to their family were more inclined to misuse BZDs as a result of the stigmatisation they felt. It was also reported in an alternate study that people with addiction are viewed by society as a marginalised group that are considered deviant (Corrigan et al. 2009). As a result of this stigma and being part of a marginalised group it could be argued that this feeds into a person’s addiction as they feel ostracised from society and could influence an addict’s life choices from negative point of view. Another societal factor that must be taken into consideration is that of economic status. In Ireland of today there are more people struggling to meet their financial obligations and this in turn leads to stress, worry and diminished coping mechanisms to deal with these pressures. These financial stressors are also bringing people into lower socio-economic groups. Stress and worry about life’s stressors has been discovered to be one of the main factors why people turn to substance misuse, which can lead to addiction and has implications in relapse of recovering addicts (Clay et al.2008, Steinberg et al. 2011). It is important to note that drug addiction is not restricted to lower socio-economic groups. Garcia et al (2012) conducted a report on addiction on medical professionals, while they found that anaesthetists were more prone to addiction, they found that there are high levels of addiction that can be attributed to stress across the medical fraternity.